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Full text of "Navy Department BUMED News Letter Vol. 5, No. 13, June 22, 1945"

NavMed 369 



RESTRICTED 




N AV Y DEPATLTM ENT 



i 





ana 



a diqest of time lLj inf oxma t i on. 



Editor - Lt. Samuel Nesbitt, (MC), U.S.N.R. 



Vol. 5 



Friday, June 22, 1945 



No. 13 



TABLE OF CONTENTS 



Motion Sickness 1 

Sjmergistic Gangrene: Therapy 2 

Pain in Wounded Men 3 

Mapharsen in Malaria .. ,. 4 

X-Ray Therapy 5 

Cornell Service Index 7 

poliomyelitis: Transmission of 7 

Shock: Anesthesia in 8 

Shock: Albumin Effects in .-.8 

Hemoglobin Injections: Effects of ... 9 

Blood Amino Acids ...9 

Tuberculosis in Navy. 10 



Wound Infection: Prophylaxis of 12 

Small Molecule Proteins 12 

Metabolic Effects of Glucose 13 

Sinuses: Pressure Effects on 14 

Vitamin C Economy in Humans 14 

Amino Acids: Tolerance to 15 

Emotional Stress: Responses to 15 

Carbon Monoxide: Elimination of ...16 

Flexner Dysentery Antigens 16 

Improvised Cautery and Ice Pack... 17 

Officers: Processing for USN 17 

Public Health Fellowships 18 



Form Letters: 



Personal Decontamination, Liquid Blister Gases BuMed ...20 

Alnav 100 - Defective Blood Plasma SecNav 24 

Alnav 103 - Inoculation Against Cholera SecNav ^..24 

Penicillin: Supply, Employment and Reporting of BuMed 25 



Treatment of Motion Sicknes s - Ineffectiveness of Benzedrine and Etched - 
rine: Since commercial preparations containing benzedrine (amphetamine) 
sulfate and ephedrine sulfate are on the market as correctives for motion 
sickness, it is pertinent to point out that neither of these drugs, used singly 
or in combination, is effective in the prevention or treatment of seasickness 
or airsickness. In one laboratory investigation, for example, it was found 



Burned News Letter, Vol. 5, No. 13 RESTRICTED 



that benzedrine sulfate in oral doses of 10 mg., given two hours before swing- 
ing, produced no significant change in the incidence of swing sickness. Other 
trials of benzedrine and ephedrine, both in this country and elsewhere, have 
proved uniformly disappointing, and there is no reason to believe that either 
of these drugs is of value in the prophylactic or therapeutic management 
of motion sickness in naval personnel. Their use for this purpose is, there- 
fore, not recommended. 

Research on motion sickness has indicated that hyoscine in a dose of 0.65 
mg., administered about one hour before the effect is desired, is effective as 
a preventive in a certain percentage of cases. This dose may be repeated 
after eight hours, but more than this should not be used without medical super- 
vision. Other motion sickness remedies developed by the Army and by the 
Royal Canadian Navy seem to be about as effective as hyoscine alone. 

Remedies for motion sickness are not recommended for routine u s e by 
naval personnel. It is clear that individuals unable to overcome susceptibility 
to motion sickness through habituation cannot be maintained for long periods 
in a state of operational efficiency by dependence on drugs, and that they must 
ultimately be removed from duties likely to produce the condition. Since pos- 
sible undesirable side effects of such drugs are not yet sufficiently well under- 
stood, this is particularly applicable to naval aviators for whom motion sick- 
ness preventives or remedies are not considered suitable, especially under 
combat conditions. 

Within the naval service, it is important to recognize those individuals 
whose operational efficiency is impaired by motion sickness and to exclude 
them from certain types of. duties. Correct initial indoctrination and training 
are of great importance in preventingthe establishment ofa sickness pattern of 
response to unusual motions. As an aid to habituation during such periods of 
indoctrination, recourse may be had to hyoscine administered under careful 
medical supervision. At sea, as well as in the air, personnel must learn to _ 
disregard, to some extent at any rate, the symptoms of sea- or airsickness. 
(Res. Div., BuMed - E. C. Hoff) , ' . 

****** 

The Treatment of Progressive Bacterial Synergistic Gangrene with Peni- 
cillin: Progressive bacterial synergistic gangrene is a serious infection 
caused by the synergistic action of a microaerophilic, nonhemoljrtic strepto- 
coccus and a Rtaphvlococcus aureus . This infection is characterized by a 
slowly spreading, superficial ulceration of the skin. The advancing margin 
is a zone of erythema in which the microaerophilic, nonhemolytic streptococ- 
cus may be found in pure culture. Within this zone, there is a raised, purple, 
necrobiotic zone which is usually extremely painful and tender to touch and on 



. . • . . ^ . ' Burned News Letter, Vol. 5, No. 13 RESTRICTED 

its inner margin, closely attached to it, there is a zone of gangrenous skin 
which has the appearance of suede leather. The inner margin of the gangre- ' , 
nous zone is slightly undermined and gradually liquefies as the process ad- 
vances. Within the necrotic zone there is a gradually enlarging, granulating 
surface where residual islands of epithelium frequently start a reparative 
process. 

The lesion most frequently develops either on the chest wall following 
the drainage of a putrid empyema or on the abdominal wall following the 
drainage of an intraperitoneal infection. Many other organisms may c o n - 
taminate these, ulcers and even become important as secondary invaders. 

Heretofore, the only cure for this condition was wide excision followed 
by the application of antibacterial agents designed to prevent the activity of 
these organisms and recurrence of the infection. The essential organisms 
are susceptible to penicillin and three cases have been reported in two of 
which a prompt cure was effected without the necessity for surgery. In the 
third case, there was improvement, but the beneficial effect of penicillin 
was nullified by the presence and activity of ^ coli and Ps. aeruginosa ( B. 
pvocyaneus ) . Penicillin in large doses should be used early in the treatment 
of this infection and may be expected to effect a cure unless the action of the 
drug is interfered with locally by secondary contaminants, which are capable 
of producing penicillinase. (OEMcmr-80 - Meleney, Friedman and Harvey - --yt 
Abstract of Ms. for Publication - March 5, '45) - , / 

' ; 3jc * + * 

Pain in Wounded Men: Severe wounds are often associated with surpris- . . 
ingly little pain. In order to get factual information on the incidence of pain, 
two hundred and twenty-five recently and seriously wounded men were con- ' 
sidered in five groups: compound fractures of long bones, extensive periph- 
eral soft tissue wounds, penetrating wounds of the thorax, penetrating wounds - 
of the abdomen, and penetrating wounds of the cerebrum. None of these men • 
was in shock at the time of questioning. As nearly as possible consecutive 
cases were considered. Ten of these had to be eliminated from consideration 
here because they were not clear mentally or were unconscious. Nine of these 
ten had penetrating head wounds. If the group of patients with head wounds is 
entirely disregarded, only one patient out of the remaining two hundred and 
one severely wounded was not alert and clear mentally. 

Patients with penetrating wounds of the abdomen had by far the most pain, 
possibly resulting from the spilling of blood and intestinal contents into the 
peritoneal cavity. Of all the patients considered, only one-quarter, on being •.. 
directly questioned shortly after entry in a forward hospital, said that their ... 
pain was enough to cause them to want medication for relief of pain. ■ 



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Burned News Letter, Vol. 5, No. 13 RESTRICTED 



Three-quarters of them did not need such relief. This was the case notwith- 
standing the f^t that the only morphine given had been administered many 
hours before. The difference between those who wanted pain-relief therapy 
and those who did not cannot be explained by differences in dosage or timing 
of the morphine administered. It is believed that morphine is too often ad- 
ministered by rote and not according to the patient's need. It would appear 
that morphine is frequently used in the belief that severe wounds are inevita- 
bly associated with severe pain, which is clearly not the case. 

In some cases, it was observed that the excitement and hyperactivity oc- 
casionally encountered in the wounded had its origin not in pain but in cere- 
bral anoxia, and more commonly in mental distress. The use of a small dose 
of a barbiturate provided great relief in the latter type of case. Small doses 
of barbiturates or narcotics will accomplish what large doses often fail to do. 
Barbiturate sedation is of great value in the treatment of the wounded man. 
He often needs the type of mental depression produced by barbiturates i n 
small dosage as much as he needs the pain depression produced by morphine. 
The man in shock complains far less frequently of wound pain than he does of 
the great distress produced by thirst. (Med. Bull. Mediterranean Theater of 
Operations, March '45 - Beecher) 

Ineffectiveness of Mapharsen as a Cure for Malaria: Much has been 
written concerning the treatment of malaria with arsenical compounds, and 
an examination of health records reveals rather widespread use of arsenical 
compounds which are intravenously administered in the treatment of chronic 
malaria. A review of the literature leaVes no doubt that the preparations 
used have some therapeutic value, although it has not been established that 
any cures have been effected by this treatment. Because of the tenacity of 
some vivax malaria infections acquired in the South Pacific area, it was felt 
justifiable to determine the actual value of mapharsen as a curative drug for 
malaria by intensive intravenous administration. 

Sixteen patients were selected, all of whom had experienced almost month- 
ly recurrences of clinical vivax malaria for a period of over two years. These 
patients were started on intravenous mapharsen and were given, in addition, a 
total of 3.2 Gm. of atabrine for a week. The dosage of mapharsen was 0.06 Gm. 
three times weekly until a total of 20 mg. per kilo of body weight was given. 
The average number of doses was 26, and the duration of treatment was from 
7 to 10 weeks. During the treatment period parasitemia disappeared; there 
were no relapses. In general, patients showed subjective improvement and 
gained in weight. 

All of the patients have been observed for one month since completion of 
treatment and some patients for two months . During this period 6 of the patients 



Burned News Letter, Vol. 5, No. 13 RESTRTCTT^D 



(37 per cent) have already relapsed. This rate of relapse within 2 months 
after this intensive course of treatment affords conclusive evidence that 
mapharsen will not cure this form of malaria acquired in the Soutja Pacific. 

Since other drugs satisfactorily curb the acute attacks' of malaria, it is 
recommended that intravenously administered mapharsen, a potentially dan- - 
gerous drug, not be employed in the treatment of relapsing, vivax malaria. 
(Marine Barracks, Klamath Falls, Ore. - L. T. Coggeshall) 

Comments on X-Rav Therapy in the Navv. In the Burned News Letter of ' 
December 28, 1944, there appeared a note advising caution in the use of X-ray 
therapy for dermatological conditions. This warning should be amplified and 
emphasized. 

X-ray and radium rays produce certain effects in living tissues, proba- ' 
bly by causing ionization in the tissue cells. In certain inflammatory condi- . . 
tions the effect of the rays, in proper dosage, is beneficial. As a general rule, 
the more acute the inflammation the smaller should be the dose of rays; also, 
when a large area is treated, the dosage must be less than that used for a small 
area. The voltage and filtration employed vary according to the depth and thick- 
ness of the lesion to be treated. 

Large doses of X-rays, or radium rays, cause destruction of tissue cells, 
and such large doses are used in the treatment of neoplasms. Even a small 
dose will cause some tissue change; the effect is cumulative, and repeated 
small doses may result in late skin or tissue changes which may be disfigur- 
ing or disabling. A large dose, given at one time, or in repeated fractions in " 
a short period of time, may cause a marked reaction, followed by late changes. 
Unfortunately, there is no immediate, visible result to warn of the impending 
damage. Repeated small doses of X-rays or radium, or repeated series of 
treatments, may cause late telangiectasis, skin atrophy, or ulceration and ne- 
crosis, even though the individual treatments or series of treatments may have 
caused little visible reaction. The therapist must know and observe the limits 
of safety in dosage. 

In some places X~ray therapy is used too freely, particularly for skin 
diseases. MacKee (X-rays and Radium in the Treatment of Diseases of the 
Skin, 3rd Edition) lists about ninety skin diseases "in which X-rays and ra- 
dium have been found useful". However, it is not good practice to use X-ray 
therapy as a routine in all of these conditions, and in only a few, probably less 
than a dozen, is X-ray therapy the best method of treatment. Whenever possi- 
ble, skin diseases should be treated by a dermatologist. When X-ray therapy 




Burned News Letter, Vol. 5, No. 13 




is used, there should be close cooperation between the dermatologist,or other 
clinician, and the roentgenologist, in order that proper cases for X-ray therapy 
may be selected and the use of incompatible drugs or local applications dur- 
ing X-ray therapy may be avoided. ■ . 

When X-ray therapy is used, it should be given by a qualified roentgen 
therapist, using accurately calibrated equipment. A complete record of all 
treatments should be entered in the patient's health record, including the fac- 
tors of voltage, filtration, skin target distance, size of fields, areas treated, 
and the dosage in r units. Such entries should be kept in the current record 
as long as the individual is in the Service. No additional roentgen or radium 
therapy should be given to any area without consulting the record of previous 
treatments. , ■ ' 

In the Navy, chronic and recurrent skin lesions should not be treated 
with X-rays. These conditions require a series of treatments over a period 
of several weeks or months, and only in a small percentage of cases are the 
results any better than with other methods of treatment. It is not a good plan 
to have X-ray therapy given at irregular intervals by several or many thera- 
pists, no one of whom will have the opportunity of continuous observation of 
the case. Such therapy is not likely to produce good results, and is most likely 
to lead to undesirable late skin changes. In any case, when the patient will not 
be available fo-r the complete course of treatment and for a proper period of 
observation, it is wise to refuse X-ray therapy. 

The two most frequent dermatological entities for which X-ray therapy is 
requested are acne vulgaris and dermatophytosis. Under ideal peacetime con- 
ditions, the value of X-ray therapy in such cases is debatable; under wartime 
conditions in the Navy, such cases should not be considered for X-ray therapy. 

In the treatment of neoplasms or any condition requiring destructive dos- 
age, the mode of therapy should be selected to fit the individual case. Consul- 
tation with surgeons, internists and other specialists should be utilized to select 
the best method of treatment. Whether surgery, electrotherapy, the use of 
X-ray or radium, or a combination of two or more of these agents be used, It 
is of vital importance that the first treatment be adequate. After inadequate 
treatment by any method, proper treatment is more difficult. This is more 
evident following inadequate irradiation than after any other procedure. When 
tissues have been subjected to relatively large doses of X-rays, there is likely 
to be delayed healing or sloughing after surgery. If adequate dosage of X-rays 
or radium is given to these damaged tissues there will probably be sloughing 
with persistent ulceration or late radiation necrosis. 

. There is seldom, if ever, a need for immediate X-ray therapy in skin dis- 
eases or superficial cancers. If the equipment at hand is not adequate and is not 




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Burned News Letter, Vol. 5, No. 13 REgTRir:Tp;p 



accurately calibrated, or if the roentgenologist has not had training and ex- 
perience in roentgen therapy, treatment should be deferred, until the patient 
can be given the benefit of proper therapy. (USNH, Portsmouth. Va. - W. H. 
Whitmore) . , • 

The Cornell Service Index : Weider et al have devised the Cornell Ser- 
vice Index (Form S) as a simple means of obtaining and evaluating psychia- 
tric data of significance from men who have been in military service for at. 
least a month. The test is self-administered and may be given to many sub- 
jects simultaneously. It can be completed by the subjects in ten minutes and 
can be scored within one minute. 

Warner and Gallico have found that the responses obtained by this test 
distinguish with a high degree of accuracy patients without apparent person- 
ality disturbances from those who present psychiatric complaints of signifi- 
cant degree. The form does not effect a very clear separation between mild 
and severe personality disturbances, although it is of some help in this dif- 
ferentiation. It is a useful research instrument in obtaining groups of patients 
for comparison according to the presence or absence of psychiatric determi- 
nants. ■ ^ 

The use of this form reveals a small number of persons with histories 
replete with psychoneurotic symptoms who are not thereby prevented from 
performing their duty adequately. This apparent discrepancy may be par- 
tially explained by the factor of motivation toward the service. The results 
obtained on the form correlate closely with the histories obtained on inter- 
view. It is, therefore, of use in obtaining histories rapidly in the psychiatric 
service or at a psychiatric consultation. 

The form does not reveal adequately the histories of subjects who are 
lacking in awareness of their difficulties. It does notuncover many cases of 
conversion hysteria, and it does not concern itself with sexual disturbances. 
It does apply adequately to the great majority of patients who come to the 
attention of the military psychiatrist, and it should prove to be of consider- ' 
able use in the evaluation of psychiatric disturbances in members of the 
Armed Service. (War Med., April '45) - ■ 

Poliomyelitis Virus in Contaminated Foo<^: Much evidence has ac- 
cumulated during recent years which suggests that the alimentary tract, 
(mouth and pharynx to colon) may be a portal of entry for the virus of polio- 
myelitis in humans. The virus has been demonstrated repeatedly in human 



Burned News Letter, Vol. 5, No. 13 , RESTRICTED 



stools, in sewage and in flies, but there has been no direct evidence that con- 
tact with infected fecal material, with sewage or with flies bears any relation- 
ship to the infection of humans by this virus. 

Ward et al have produced subclinical infections or carrier states of polio- 
myelitis in chimpanzees by feeding them with food which had been exposed to 
flies in the homes of patients with the disease during an epidemic. The virus 
of poliomyelitis was demonstrated in the stools of these chimpanzees by the 
intracerebral inoculation into rhesus monkeys of suitable preparations of the 
stools. (Science, May 11, '45) 

5jc 5|< 3|v 5^ Sfi 

• ( 

General Anesthesia in Shock : Crooke and his associates have indicated 
that operations on seriously shocked patients are associated with an extreme- 
ly high mortality. This may. be due to further loss of blood entailed during 
the operation, to the stimulus of the operative manipulations, or to the anes- 
thesia. It has become apparent that the most important single factor has been 
the anesthesia, and an examination was therefore made of the effects of dif- 
ferent anesthetic agents on the cardiovascular systems of 26 patients with 
normal plasma volumes, of whom 19 underwent major operations. 

The anesthetics used were nitrous oxide, oxygen and ether, cyclopro- 
pane and oxygen, sodium pentothal and spinal analgesics. In all cases the 
pulse, respiratory rate and blood pressure were recorded at about thr ee - 
minute intervals. Determinations of plasma volume were made, and the dye 
concentration curves were followed at about thirty-minute intervals until ^ 
the end of the operation. The hemoglobin was also determined at the same 
intervals. Electrocardiographic records were made of nine of the patients. 

No significant changes were found, except that great alterations in blood 
pressure occurred. It was concluded that anesthetic agents affect blood 
pressure mainly through the vasomotor system. Cyclopropane and oxygen 
tended to raise the blood pressure; nitrous oxide, oxygen and ether had vari- 
able effects on it; sodium pentothal and spinal analgesics depressed it. In a 
patient whose plasma volume was reduced by trauma there was a greater 
tendency for these anesthetics to depress blood pressure. In this series it 
was concluded that a combination of cyclopropane and oxygen was the best 
anesthetic and nitrous oxide with adequate oxygen and a minimal amount of 
ether was the next best anesthetic. (Brit. M. J., Nov. 25, '44) 

* + + + + * 

Circulatory E ffects of Human Albumin Solutions in Patients with Shock : 
Concentrated human albumin without additional crystalloid solution was injected 



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Burned News Letter, Vol. 5, No. 13 RESTRICTED 



into twenty-two surgical patients with hypotension and oligemia. Circulatory 
measurements were made before, 20 minutes after and, in eleven cases, two 
and one -half hours after the injection. The results indicate that the injected 
albumin produced a decrease in hematocrit (average from 39 to 33) and an 
increase in plasma volume (average 11.4 cc. per Gm. of albumin injected). 

The mean arterial blood pressure, although it rose approximately 17 mm. 
Hg., did not return to, the accepted normal level. This confirms previous ob- 
servations that following rapid hemodilution with a decrease in the apparent 
blood viscosity, changes in arterial blood pressure are not an adequate index 
of the restoration of the circulation. In other words, in these cases, the cir- 
culation was satisfactorily restored although mean arterial blood pressures 
were still subnormal, (OEMcmr-107 - Cournand, Columbia Univ. - CMR - 
Bulletin #38) 

Renal Function of Dogs Given Oxyhemoglobin or Methemoglobin Solutions : 
After withdrawal of 50 cc. of blood per kilo from dogs, anuria resulted for 
about 12 hours unless the withdrawn, blood was replaced by other fluid. Re- 
placement of the blood by an equal volume of sterile plasma, 7.6 per cent oxy- 
hemoglobin, or 7.6 per cent methemoglobin solution, at once restored the flow 
of urine. 

The urea clearance of dogs infused with plasma or oxyhemoglobin solu- 
tion returned to preoperative levels the day following infusion, except in the 
case of one dog infused with oxyhemoglobin. This animal showed an unex- 
plained transitory fall in urea clearance on the third postoperative day. In 
dogs infused with methemoglobin solution, the urea clearances remained de- - . 
pressed to about one -third normal for three days, returning to normal ,, 
during the next three days. Renal function then remained normal. 

The half -life of either injected oxyhemoglobin or methemoglobin in the - 
circulating plasma was about eight hours. All pigment disappeared in 72 hours. 
During circulation in the plasma little infused oxyhemoglobin changed to methe- 
moglobin, but a large part of infused methemoglobin changed to active hemo- 
globin. From 30 to 40 per cent of the injected pigment, infused as either oxy- 
hemoglobin or methemoglobin, was excreted in the urine, (OEMcmr-67 - Van 
Slyke, Rockefeller Inst, for Med. Res. - CMR Bulletin #38) 

^ 5^ ^ 5jt ^ 

Si gnificance of Blood Amino Acid Concentration: Surprisingly little work 
has been done by recent methods upon the physiologic variants of the amino acids 
of the blood. Nevertheless, variations in the concentrations of amino acids in 



Burned News Letter, Vol. 5, No. 13 RESTRIi 



blood, as determined by these methods, are being interpreted without ade- 
quate physiological controls. It has been assumed that the concentration of 
amino acids in the serum might serve as an index of the metabolism of pro- 
tein in the body. In the course of studies of the nitrogen metabolism in vari- 
ous diseases, data have been accumulated that cast some doubt upon this 
concept. 

In a variety of patients with infectious diseases, injuries and surgical 
operations, the blood amino acid concentration (by the ninhydrin method of 
Hamilton and Van Slyke) showed little correlation with the total turnover o f 
protein (the total nitrogen intake or nitrogen output, whichever was larger , 
during the preceding 24 hours) . 

It is noteworthy that, despite the fact that the turnover of protein usually 
exceeded 100 Gm. per day, in only three instances did the concentrations of 
amino acids exceed the normal limits (in each instance by a negligible amount), 
while in eleven instances the amino acids fell below the normal limits. One of 
the patients with the highest turnover of protein, more than 200 Gm., had the 
lowest amino acid concentration in the series. (OEMcmr-420 - Man and Waife, 
Yale Univ. - CMR Bulletin #37) 

The Diagnosis and Disposition of Cases of Minimal Pulm onary Tubercu- 
losis: The mass screening of Naval and Marine Corps personnel by photo - 
fluorography has resulted in a significant increase in the percentage of cases 
discovered of minimal pulmonary tuberculosis. All cases in which suspicious 
shadows are present in the photofluorogram are subjected to clinical study for 
diagnosis and disposition. The full responsibility for the prognosis of such a 
case rests on the judgement of the medical officer in establishing the diagnosis 
and in recommending proper disposition of the case. Account must be taken of 
the activity of the lesion and the possible effect of continued naval service on It. 
Cases are on record in which lesions of minimal tuberculosis were missed on the 
photofluorogram or were considered to be of no clinical significance by the cogni- 
zant medical of ficer , and which progressed under service conditions to a moder- 
ately advanced or far advanced stage before again coming under medical care. 

The physician in charge of the photofluorographic unit is charged with the 
responsibility of the screening process and of recommending for further clini- 
cal study all cases in which a pathological lesion is suspected. Listed below 
are the causes for rejection for original entry into the Service according to 
the directive, BUMED-Y-DFS, P3-3/P3-l(054-40), dated 4 Jan 1945: 

(a) Any evidence of reinfection (adult) type tuberculosis, active or inactive, 
other than slight thickening of the apical pleura or thin solitary fibroid strands. 



Burned News Letter, Vol. -5, No. 13 RESTRICTED 



Cb) Evidence of active primary (childhood) type tuberculosis. 

(c) Extensive multiple calcification in the lung parenchyma, or massive 
calcification in the hilus, or any calcification of, questionable stability. 

(d) Evidence of fibrous or sero-fibrinous pleuritis, except moderate 
diaphragmatic adhesions with or without blunting or obliteration o f t h e 
costophrenic sinus. 

(e) Other disqualifying defects demonstrable by a roentgen examination 
of the chest (See paragraph 1477, Manual of the Medical Department). ■ - 

Under this same directive, these conditions are, in addition, causes for 
further clinical study of personnel who have been previously accepted for 
naval service. Once the individual with a suspected pathological lesion has 
been hospitalized, the full responsibility for the clinical investigation and 
diagnosis rests upon the medical officer of the hospital. 

When a suspicious roentgenological shadow is demonstrated, a diagnosis 
must be established. Ordinarily this can be accomplished only after a period 
of weeks of careful investigation. A detailed history and a thorough physical 
examination are necessary. Although pulmonary tuberculosis in its early 
stages is not often associated with appreciable symptoms or physical signs, 
observation of the patient's course will assist materially in differentiating 
the suspected lesion from pneumonia, bronchiectasis, lung abscess, neo- 
plasm, chronic upper respiratory infection, pulmonary fungus infection and 
the various pulmonary fibroses. A tuberculin test should be done, a proce- 
dure of particular value for ruling out tuberculosis when a negative result is 
obtained. 

Repeated examinations of sputa for tubercle bacilli should be made on 
specimens which have been concentrated. The proper collection of the speci- 
men is as important as a painstaking laboratory examination. Saliva is too 
often sent to the laboratory as a result of lack of instruction of patients . 
When repeated specimens have been found negative, cultures and inoculation 
of animals- should be done. When all other methods have failed, and in pa- 
tients who have little sputum, attempts should be made to demonstrate tuber- 
cle bacilli by smear, culture and inoculation into animals of concentrated 
stomach washings. 

In order to determine whether or not a lesion is active, it is necessary 
to obtain a series of X-ray films over a period of weeks. The patient 's 
temperature should also be followed carefully and laboratory procedures 
must include, in addition to careful sputum studies, sedimentation rate of 
erythrocytes and white and differential blood cell counts. 



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Extreme caution should be exercised in returning a man to duty with 
the established diagnosis of "reinfection tuberculosis, minimal, arrested". 
If his disease is not actually arrested, the one qpportunity of affecting a cure 
may thus be lost, and the prognosis of his disease completely altered. The 
1940 edition of "Diagnostic Standards", published by the National Tuberculo- 
sis Association, classifies pulmonary tuberculosis as arrested only after a 
period of six months' observation during which time the X-ray lesions have 
remained stationary, constitutional symptoms have been absent, and concen- 
trated sputa, examined at monthly intervals, have been negative for tu- 
bercle bacilli. CPrev. Med. Div., BuMed - T. J. Carter) 



Prophylaxis of Wound Infection: Peterson has investigated the prophy- 
laxis of wound infection in dogs. Both clean and contaminated wounds were 
studied. There is no doubt as to the efficacy of the various soaps as germi- 
cidal agents. However, in these experiments, when the soaps were placed in 
actual contact with uncontaminated fresh wounds, they produced a definite but 
slight irritation. This was noted only on microscopic examination; gross ex- 
amination revealed no difference between control wounds and wounds into 
which soap had been placed. However, in wounds which were contaminated by 
placing a given amount of a culture of Staphylococcus aureus within their depths 
and then were exposed to soap, there was a definite increase in signs of in- 
fection over those found in the control wounds not exposed to soap; "green" 
soap was found more irritating than "white" soap. 

The harmful effect of mechanical washing of the wounds is in direct pro- 
portion to the coarseness of the material used. These experiments indicated 
that of the various methods studied the cleansing of contaminated wounds by 
a gentle irrigation with isotonic solution of sodium chloride is the most effec- 
tive prophylaxis of wound -infection. Contaminated wounds treated by this 
gentle irrigation healed with less evidence of infection than did control c o n - 
taminated wounds subjected to no treatment other than closure. Best results 
in cleansing these small wounds were obtained by irrigating them with 1,000 
cc. of saline solution with no scrubbing, utilizing the force of the stream as 
the washing mechanism. (Arch. Surg., April '45) 



Effects of Small Molecule Proteins When Injected Parenterali y. In the 
preparation of blood substitutes, conditions may arise in which a partial hydro- 
lysis of protein occurs. The solution may then contain a certain proportion of 
small molecules. When protein molecules that have a smaller molecular weight 
than serum albumin (egg white and Bence- Jones' protein) are injected parenter- 
aliy, they filter through the glomerular membrane and appear in the urine even 



* 



* 



( 



* 



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Burned News Letter, Vol. 5,. No. 13 RESTRICTED 



when small quantities are given. When bovine albumin (Cohn) is used, how- 
ever, no increase in protein excretion occurs until large amounts have been 
injected. With human gamma globulin CCohn) the largest amounts that can be 
given produce no such effect. 

When egg white, diluted in 0.85 per cent sodium chloride, was injected in- 
to rats, there was, after three hours, an increase in hematocrit, in serum 
urea and in protein in the urine. After six hours the hematocrit was higher 
(56.2), serum urea was very much elevated (100.4 mg. per cent), and urea 
clearance was zero. By 17 hours after injection, appreciable amounts of 
fluid were present in the pleural cavities. Animals sacrificed 48 hours after 
the injection showed only slight residual effects. 

These findings are interpreted to mean that the egg albumin entering the 
blood stream passed through the capillaries into the subcutaneous tissue 
spaces where it drew water by means of its colloid osmotic pressure. Be- 
cause of this, the blood volume became so reduced that renal failure ensued. 
Recovery occurred when the animals were able to drink enough water to re- 
store their blood volumes. At this point, however, a marked subcutaneous ede- 
ma developed, as indicated by the accumulation of fluid in the pleural cavities. 
(OEMcmr-338 - Addis, Stanford Univ. - CMR Bulletin #39) 

Water- and Nitrogen- Sparing Effect of Glucose Ingestion : Experiments 
have been conducted to determine the extracellular and intracellular water 
and tissue -sparing effects of glucose in otherwise fasting individuals. Glu- 
cose was given in amounts of 50, 100, 200 and 300 Gm. daily over a period 
of six days. Under conditions of moderate activity, the acetonuria of starva- 
tion was found to be very greatly reduced by ingestion of 50 Gm. of glucose 
per day and almost completely abolished by a dose of 100 Gm. of glucose per 
day. Approximately the same reduction in urinary nitrogen excretion was ac- 
complished with 100 Gm. of glucose per day as with 300 Gm. per day. On a 
limited fluid intake the ingestion of more than 100 Gm. of glucose per day is 
frequently nauseating. 

When an intake of 100 Gm. of glucose per day was supplemented by amounts 
of purified casein, egg protein and wheat germ to replace the 7 Gm. of nitro- 
gen lost in the urine, there resulted but an insignificant improvement in the 
nitrogen balance. The ingestion of such protein causes an increased demand 
for the urinary excretion of catabolites, and thus tends to augment the mini- 
mum urine volume and minimum water requirement by approximately 200 cc. 
per day. {OEMcmr-478 - Butler, Mass. Gen. Hosp. - OMR Bulletin #40) 



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Burned News Letter, Vol. 5, No. 13 RESTRICTED 



Effect of Pressure Changes on the Sinuses : The paranasal sinuses when 
subjected to pressure changes present a situation similar to that of the mid- 
dle ear. If the openings into the sinuses are noj-mal, air passes into and out 
of these cavities without any difficulty at any practical rate of ascent or de- 
scent, thus assuring adequate equalization of pressure at all times. If the 
openings of the sinuses are obstructed by swelling of the mucous membrane 
lining, caused by infections or an allergic condition such as hay fever, or if 
the openings are covered by redundant tissue on which viscous secretions 
are, present, ready equalization of pressure becomes impossible. 

The pressure gradient that is established in pathological conditions dur- 
ing change of altitude produces a pressure differential causing marked pain. 
Unlike the internal ears, the sinuses are almost equally affected by ascent , 
and descent. If the frontal sinuses are involved, the pain extends over the 
forehead above the bridge of the nose; if the maxillary sinuses are affected , 
the pain is on either side of the nose, in the cheekbones. Maxillary sinusitis 
■ may produce pain referred to the teeth of the upper jaw, and may thus be mis- 
taken for aerddontalgia. The pain of aerosinusitis, though often of the same 
type as that caused by ordinary sinusitis at ground level, may be much more 
severe and fulminating in the event of sudden blockage during rapid change in 
altitude. 

Equalization of pressure to relieve pain in the sinuses is best accom- 
plished by yawning, swallowing or blowing with the nose and mouth closed. 
Treatment of aerosinusitis should be directed to the obstructed orifices, 
which usually can be opened by shrinking the nasal mucous membranes with 
any preparation ordinarily used for this purpose, such as the benzedrine in- 
haler" or a 0.5 per cent solution of neosynephrin hydrochloride. If there is 
persistent recurrence of aerosinusitis, a search should be made to deter- 
mine the possible presence of tumors, polyps, scar tissue or other causes of 
obstruction about the openings of the sinuses in the nose. (Physiol, of Flight, 
March 15, '45) 

"t" ^ 

Vitamin C Economy in Human Subjects : Six subjects were saturated with 
ascorbic acid (400 to 500 mg. daily for from four to six days) and then were 
placed on a diet lacking in vitamin C but adequate in all other respects. None 
of the subjects developed scurvy until from five to six months had elapsed, and 
all appeared to be in good health until two weeks prior to the onset of the dis- 
ease. Gingivitis appeared only in one case following the advent of perifollicu- 
lar hemorrhages. 

It would appear that the quantity representing an adequate intake of vita- 
min C should be between the protective minimum ( 18 to 25 mg. daily) and the 



Burned News Letter, Vol. 5, No. 13 , RESTRICTED 



amount required to maintain saturation as evidenced by excretion of vitamin 
C in the urine (80 to 100 mg. daily). In the absence of clinical evidence, this 
quantity is largely a matter of conjecture. (Bull. -Johns Hopkins Hosp., Nov. '44 - 
Pi joan and Lozner ) - . • . ■ . 

Tolerance to Amino Acid Mixtures and Casein Digests: Several synthe- 
tic mixtures of natural and racemic, crystalline, amino acids suitable for 
the daily nitrogen requirement have been tested for tolerance in dogs when 
administered intravenously. Certain mixtures of the ten essential amino 
acids plus non-essential amino acids, exclusive of glutamic acid, were ad- 
ministered without any resultant obvious sign of disturbance even at rates 
above 10. mg. of nitrogen per kilogram of body weight per minute for quanti- 
ties greater than 300 mg. per kilo. 

When glutamic acid, natural or racemic, was included in similar mix- . 
tures, vomiting reactions frequently occurred when injected at rates above 
4 mg. per kilo per minute. Vomiting almost always occurred on the first 
daily injection containing glutamic acid and usually on any subsequent injec- 
tion containing more than 100 mg. of glutamic acid per kilo unless given very 
slowly. Upon the addition of glycine, certain mixtures of the ten essential 
amino acids were better tolerated. 

Two samples of casein digests which were tested usually produced vomit- 
ing at injection rates above 2 mg. of nitrogen per kilo per minute, probably 
because of their content of glutamic acid. No serious reaction has ever 
occurred as a result of the administration of any mixture of amino acids or 
casein digest tested. Elimination of minor reactions, such as vomiting, ap- 
pears possible and is desirable for greater usefulness of these solutions in 
parenteral feeding. (J. Exper. Med., May 1, '45 - Madden et al) 

Stress as a Cause of Cardiorespiratory Disturbances: Observations > 
were made in apparently healthy individuals of the levels of the pulse rate, 
blood pressure , circulation and respiration after a fixed amount of exercise and 
during the usual and unusual emotional states which occur in the course of 
everyday life. Observations over a ten- month period have revealed the fol- 
lowing: On most days the pulse rate , blood pressure , cardiac output (ballisto- 
cardiograph) , and minute ventilation returned to the resting level within 
three minutes after exercise. It was noted, however, that on days when fear, 
anxiety, resentment, and tension were present, the return of these functions 
to the resting levels was dramatically delayed. 



r r 

Burned News Letter, Vol. 5, No. 13 RESTRICTED 



Patients with neurocirculatory asthenia showed these same responses 
to exercise, and in one the mere recall of the stress -producing situations 
resulted in increased blood pressure, cardiac output and ventilation, 
(OEMcmr-508, Wolff, Cornell Univ. - CMR Bulletin #40) 

* + + * + * 

Fate of Radioactive Carbon Monoxide Administered to Human Subjects : 
It has been found that a third or more of the carbon monoxide lost from the 
blood appears to be lost by some route other than the expired air. Recently 
radioactive CO has been used to study this problem. 

Radioactive CO was administered to four normal subjects , and the expired 
CO2 was absorbed in soda lime during 15-minute periods thereafter. The 
maximum conversion to radioactive COg during the periods under study was 
less than 1 part in 1,000 of the expired CO. Gregersen believes that this is 
the first, really decisive proof that no appreciable oxidation of CO occurs in 
normal man. 

About 150 cc. of CO was administered to three normal subjects, and the 
whole of their expired air collected for four hours thereafter, the subjects 
breathing 02 during this time. B'rom 95 to 96 per cent of the originally ad- . 
ministered CO was recovered in the expired air during the four hours of 02 
breathing. These results seem to prove that most of the missing CO in the 
first hour had combined reversibly with extracirculatory pigments, the ex- 
tent of such combination being greater than was hitherto suspected. 

i 

In the hour after administration of radioactive- CO, Geiger counters indi- 
cated a much greater concentration of activity over the liver than over other 
areas, such as over thigh muscles. (OEMcmr-66 - Gregersen, Columbia 
Univ. - CMR Bulletin #40) 

The Somatic Antigens of Flexner Dysentery Bacilli: The somatic anti- 
gens of Sh igella oaradysenteriae (Flexner) strains have been isolated by a 
modified acid-extraction procedure which has been successful in the isola- 
tion of the "M" protein of Group A, hemolytic streptococci and of the sur- 
face antigen of IL pertussis . These dysentery antigens have been studied sero- 
logically by immunization and absorption methods, and have been found to be 
the principal cellular components concerned in agglutination, mouse protec- 
tion and precipitation of the specific antigen or carbohydrate. Studies of 
toxicity and antigenicity with these somatic antigens in humans, rabbits and 
mice show no definite advantage of the isolated fractions over the whole 
killed bacteria as active immunizing agents. These materials are extremely 



Burned News Letter, Vol. 5, No. 13 RESTRICTED 



antigenic. In one instance, in mice, as little as 0.007 microgram was capa- 
ble of inducing 50 per cent protection against 100,000 M.L.D. of homologous 
infecting organisms. (OEMcmr-120, Smolens et al, Univ. of Pa. Ms. for 
publication. C MR Bulletin #39) - . 

+ * jjc * + * 

Improvised Electric Cautery and Tee Pack Bag: A recent report from 
the 47th Construction Battalion describes methods of improvising in the field 
two items which may be of interest to personnel of the Medical Department: 

Electric Cautery : A lightweight tool for cauterizing may be constructed 
from materials available in any field electric shop. Holes are drilled to a 
depth of 1/2 inch in the ends of two pieces of No. 6 bare copper wire, sixinches 
in length, to receive #20 gauge monel heating wire. Holes are drilled in the ■ 
sides of the copper wire for set screws to secure the heating unit which can 
be fashioned in any form for the operation required. The two copper wires 
are taped together, being separated by an insulating material such as mica or 
fibre, fitted into a light wooden handle, and attached to an extension cord. A 
direct current of 180 amps - one and one -half volts - may be employed with 
this apparatus. Six ordinary dry cells in parallel, or a rectifier or D . C . 
Generator source may suffice. 

* * 

Tee Pack Bag: An ice pack bag may be constructed froin a piece of dis- 
carded inner tube which is cut to the desired size and the cut ends vulcanized 
or patched. A threaded cap, such as may be cut from an old kerosene can, 
is procured. A small hole is cut into the center of the closed tube, the screw 
cap body is inserted and secured by vulcanizing or by the use of rubber cement. 
(Report from the 47th Construction Battalion, Feb. '45) 

S|C 3^! 5^ 5^^ 

Examination of Candidates for Appointment to Officer Rank in Regular 
Navv : The following extract of BuPers Circular Letter 274-43, dated 27 Dec 
1943, is provided for the information of medical officers and to assist them 
in the proper procedure to be followed in processing examinations of candi- 
dates for appointment to officer rank in the regular Navy. Medical officers 
frequently fail to enclose the certificate indicated in section 2 below: 

1. The Secretary of the Navy has recently approved a change in procedure in 
processing the examinations of all candidates for permanent appointment to 
commissioned and warrant rank in the regular Navy. Pursuant to the new pro- 
cedure, the reports of naval examining boards and boards of medical examiners 



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Burned News Letter, Vol. 5, No. 13 RESTRICTED 



will not be forwarded to the Office of the Judge Advocate General but to the 
Chief of Naval Personnel and the Bureau of Medicine and Surgery, respec- 
tively. 

2. The reports of the various boards of medical examiners will be made 
only on the appropriate BuMed form and will be signed by each member of 
the board present and acting. BuMed Form Y is prescribed for all candi- 
dates other than Naval Reserve aviators; in the latter cases, Form I. The 
following certification shall be included in the report: ''We hereby certify 
that the candidate is (not) physically qualified for appointment in the United 

States Navy as an \ There must in every 

case be appended to the report a certificate, sworn to by the candidates, as 
follows: 

"I certify that I have informed the board of medical examiners of all 
bodily or mental ailments which I have suffered and that, to the best of my 
knowledge and belief, I am at present free from any bodily or mental ail- 
ment." 

3. A candidate who is found not physically qualified by a board of medical 
examiners will be so advised and will be informed that, if he so desires, he 
may undergo the written professional examination. In such a case, the candi- 
date must understand that approval of the findings of the board of medical 
examiners in the Department will bar him from appointment notwithstanding ' 
the fact that he may be found professionally qualified. 

--BuPers. L. E. Denfeld 

The complete text of Circular Letter 274-43, Pers - 322-KD, P14-2, 
"Procedure in Processing Examinations of Candidates for Appointment to 
Officer Rank in Regular Navy", may be found in the Navy Department Semi- 
monthly Bulletin of December 31, 1943. (Med. Records Div., BuMed - C. R. 
Ball) 

National Institute of Health Research Fellowships: The Public Health 
Service has announced the creation of National Institute of Health Research 
Fellowships. These fellowships offer an opportunity for study and research 
in association with highly trained specialists in the candidate's chosen field 
at the Institute or some other institution of higher learning. Further infor- 
mation may be obtained from The Director, National Institute of Health, 
Bethesda 14, Maryland. 



+ + + * 



Burned News Letter, Vol. 5, No. 13 



RESTRICTED 



Public Health Foreign Reports: 



Disease 


Place 


Date 


Number of Cases 


Cnoiera 


India, Calcutta 


April 1-11, 40 


(4D K^oo latai; 


Plague 


Ecuador 


Marcn o-iu, ^to 


1 ■ ■ 

x ■ 




higjrpi, i-'ort baiu 


TPoVi 1 n 94 MR 
rSD. X'J~ci'±j to 






Maaagascar 


reo. 1-iu, lu 


R 
tJ 




Morocco (French) 


Marcn ^Ji- April lu, lo 


97 




Peru 


i^eD. 


ij w laiai ) 


Smallpox 


British E. Africa, 


Marcn Z4-oi^ 40 


oiu \io laiai / 




Tanganyika 


March 10-17, '45 


245 (10 fatal) 




Cameroon (French) 


March 21-31, '45 


195 




Egypt 


/Tfj v>/->in in 1 7 'AR 

Marcn lu-i 1 , 40 


R7 
0 ( 




French Guinea 


1:1 eo. Zl-April lU, 40 


RQA 
Do4 




Nicaragua, Managua 


Jan. 40 


1 9"^ 




Nigeria 


Jan. ijf-March lu, 4o 


DOo too latai ; 




Sudan (French) 


Marcn ^ii- April lU, 40 


OAQ 




Togo (French) 


Feb. i^i-^o, 40 


1 Q7 
10 f 




union 01 o. Airica 


To n ' A R 

Jan. 40 






Venezuela 


reD. -Marcn 40 


^DD laiai ) 


Typhus 


Algeria 


Marcn i-^iu, 40 


1 "^9 


Fever 


Bulgaria 


March -::4-ol, 4o 


y4 




Chile 


Jan. ^b-Feb. ^4, 4o 


di to latai ; 




Ecuador 


March '45 


37 (3 fatal) 




. Egypt 


Feb. 3-10, '45 


' 375 (57 fatal) 




March iU-l ( , 4o 


f Dy \0 1 latai; 




Libya, Tripolitania 


Jan. 40 






Morocco (French) 


April 1-lU, 4o 


RRQ 
ODO 




Turkey 


Tv/T'!! viz-iVi Q in 'AR 

Marcn o-iu, 4u 


00 






April 7-21, '45 


190 




Union of S. Africa 


Jan. '45 


158 (18 fatal) 




Venezuela 


Feb. -March '45 


29 (2 fatal) 




Yugoslavia, Croatia 


Jan, 1-21, '45 


137 


Yellow 


Ivory Coast, Guiglo 


March 13, '45 


1 (fatal) 


Fever 


Peru, Quincemil 


April 17, '45 


1 




Venezuela, Dantas 


Feb. 19, '45 


1 (fatal) 




Buen Retire 


April 12, '45 


1 



(Pub. Health Reps., April 6, May 11 & 18, '45) 



- 19 - 




r 



RESTRICTE D 



To: 



All Ships and Stations. 



BuMed-X-BLW:II 
F34-5 



Subj: 



Personal Decontamination, Liquid Blister Gases. 



9 May 1945 



Refs: (a) BuMed Itr "Prevention and Decontamination of Mustard Gas and 
Lewisite Casualties by Use of S-461 Ointment and HAL Ointment, 
Dii;ections for"; N. D. Bui. Cum. Ed. 1943, 43-1094, p. 473. 
Cb) BuMed itr ''Personal Decontamination, Liquid Vesicant Gases"; 
AS&SL Jan-Jun 1944, 44-97, p. 345. 

1. GENERAL. 

(a) This circular letter is issued as a modification of reference (b) . All 
previous instructions in conflict therewith are canceled. 

Cb) A specific routine of personal decontamination - that is, self-aid - 
must be accomplished at once, as prescribed below, if serious eye and skin 
damage is to be prevented after contamination by liquid blister gas. 

This is the individual responsibility of all naval and marine personnel. 

Cc) However, if battle conditions at the time of exposure compel uninter- 
rupted manning of guns and stations, then personal decontamination shall be 
accomplished at the earliest possible moment when tactical conditions permit. 

■ DECONTAMINATION OF THE EYES. 

(a) Eye shields. The eye shields, supplied' to each individual, shall be 
worn at all times during periods of gas hazard. This prevents contamination 
of the eye from spray and splashes of liquid blister gases. Periods of hazard 
would include the handling of vesicant munitions, the use of blister gas in 
training programs, and at all times when in the open and within range of the 
enemy aircraft after chemical warfare has been initiated. The eye shields, 
properly used, constitute the real solution to the problem of eye injuries due 
to blister gases. If the eye shield is worn, it must be discarded after contami- 
nation. 

(b) Previous instructions for decontamination. Previous directives con- 
tained in references (a) and Cb) have stated that irrigation alone should be 
used as personal decontamination for liquid mustard contamination of the eye. 
Recent studies have shown that BAL ointment followed by irrigation is super- 
ior to irrigation alone. A further advantage of this new personal decontami- 
nation procedure is that the individual has to remember only one procedure, 
since it may be used for all liquid blister gas contamination of the eye. He 

is therefore not compelled to distinguish between different contaminating 
agents at a time when t-his might be impossible. 



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Burned News Letter, Vol. 5, No. 13 RESTRICTED 



(c) New procedure. 

(1) All contamination of the eyes by any liquid blister gas, whether 
mustard, nitrogen mustards, lewisite (or other arsenical vesicants) or mix- 
tures thereof, is handled by a new decontamination procedure. This combines 
the use of BAL ointment, massage and irrigation. Immediately after contami- 
nation by any liquid blister gas, BAL ointment is squeezed directly into the 
lower eyelid. If the eye cannot be opened, as after contamination by lewisite, 
either alone or in mixtures, the ointment is applied to the eyelids and rubbed 
well. Sufficient ointment will enter between the lids to relieve pain and 
spasm to such an extent as to make it possible to open the eye. Ointment shall 
then be instilled directly into the lower sac. The lids are then closed and mas- 
saged for 1 minute. This is followed by irrigation of the eye with water from 
the canteen or other available uncontaminated source. The head is thrown 
back, the lids are forced open with the fingers of one hand, while the water is 
poured into the eye from a container in the other hand. The water shall be 
poured directly and slowly into the eye for at least 1/2 minute, or until the 
canteen is empty, but not longer than approximately 2 minutes. If BAL oint- 
ment is not immediately available, the eye shall be irrigated immediately 
with water without waiting to obtain the ointment. The decontamination must 
be completed before the gas mask is put on in spite of possible exposure to 
vapor during decontamination, 

(2) Liquid mustard alone in the eye causes no immediate pain or dis- 
comfort, but when BAL ointment is placed into an eye contaminated with this 
agent there will be immediate irritation and spasm.. This is to be expected 
and personal decontamination or self- aid should not be stopped because of 

it. The irritation from the ointment ceases as soon as the irrigation is be- 
gun. However, the irrigation should not be stopped as soon as the stinging 
disappears, but should be continued for 30 seconds to 2 minutes. 

Cd) Precaution, 

CI) BAL ointment placed in an uncontaminated eye is very irritating 
and causes immediate stinging and spasm which may interfere with the indi- 
vidual's combat ability for a period up to 15 minutes. Therefore, the oint- 
ment should be used in the eye only when the individual is fairly certain that 
his eye has been contaminated by some form of liquid blister gas. The chance 
of liquid contamination is slight except when in the close vicinity of a shell 
or bomb burst, or in the path of a direct airplane spray. 

(2) The fact that the individual tubes of BAL ointment do not nave 
printed on them directions for use against mustard, nitrogen mustards, and 
mixtures of these with lewisite is not to be construed as a contraindication 
to its use against these agents. 



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Burned News Letter, Vol. 5, No. 13 ' RESTRICTED 



(e) Effectiveness of BAL ointment. In contamination of the eye by liquid 
mustard alone, the initiation of self- aid within the first few seconds is mar- 
kedly effective and after 2 minutes is of very little value. In the case of con- 
tamination of the eye by liquid lewisite or any other arsenical vesicant, BAL 
ointment is effective for a longer period of time. If it is used within 1 minute 
after contamination, the eye usually recovers in a few days. When it is used 
10 minutes after contamination, the eye requires several weeks to heal and 
usually suffers permanent damage. BAL ointment has almost no effect after 
30 minutes. 

3. DECONTAMINATION OF THE SKIN. 

(a) Previous instruction. Previous directives contained in references (a) 
and Gd) stipulated that the individual in the field should decontaminate against 
mustard blister gas by the use of S-461 protective ointment, A new protective 
ointment designated as Protective Ointment S-330 has since been developed, 
issues of which were authorized as of 7 December 1944. 

0^) Change in standard procedure. An individual at the time of the gas 
attack, whether by airplane spray, shell or bomb burst, may be unable to 
ascertain the exact nature of the agent. The hazard of encountering liquid 
lewisite alone appears small. Liquid lewisite, due to its property and action, 
is not likely to be used by the enemy other than as a mixture with other blister 
gases. In view of this situation, the individual shall carry out the following 
procedure when contaminated with any liquid blister gas unless directed other- 
wise by local authority: 

(1) The free liquid blister gas is blotted from the skin with the absorb- 
ent cloth wrapped around each tube of S-330 protective ointment or by using 
any absorbent material at hand. Discard the used absorbent. Protective 
Ointment S-330 is then applied freely to the area and thoroughly rubbed into 
the affected areas with the fingers for about 15 seconds. The excess is im- 
mediately removed. In the case of large splashes, the ointment shall be 
applied and removed once more. 

C2) The BAL ointment- is then spread on the skin in a thin film, rubbed 
in with the fingers, allowed to remain at least 5 minutes, and reapplied. BAL 
ointment sometimes causes temporary stinging and itching urticarial wheals 
when applied to the skin. These lesions usually last only an hour or so and 
should not cause alarm. Mild dermatitis is fairly frequent if repeated appli- 
cations are made to the same skin area. This prevents the use of BAL as a 
protective film. 

(3) The decontaminated skin area should be thoroughly washed with 
soap and water as soon as practicable following decontamination if such facil- 
ities are available. 



Burned News Letter, Vol. 5, No. 13 



RESTRICTED 



(4) The individual must familiarize himself with the two ointments. 
He should know that the large 3-ounce tube contains S-330 protective oint- 
ment and the smaller 1-1/2 ounce tube BAL ointment. 

(c) Mustard alone. Personal decontamination or self-aid is the removal 
of liquid mustard at the earliest possible instant by the individual himself. 
The importance of prompt action cannot be over stressed. Proper skin decon- 
tamination from mustard during the first minute is always successful. After 

3 minutes on the hot sweaty skin, or 5 minutes on the cool dry skin, no method 
of decontamination will prevent blistering. Decontamination should be per- 
formed, however, no matter how delayed, as long as liquid mustard is still 
present as it may be of some value. Areas of skin contaminated with liquid 
blister gas, whether protected by the ointment or unprotected, must be decon- 
taminated as soon as possible. Blot off the excess agent from the skin as de- 
scribed under Change in Standard Procedure, paragraph 3(b), (1) and (3). If 
the contamination with blister gas is light, no 'blotting is necessary but gener- 
ous application of ointment, protective, S-461, or S-330 (preferably the latter), 
with thorough rubbing will be sufficient. If redness of the skin has appeared 
before decontamination with protective ointment S-461 or S-330 has been con- 
ducted, cleanse the area with soap and water. Protective ointment is irritatng 
to the reddened skin and shall be used only when liquid mustard is still present 
and soap and water are not available for thorough washing. 

(d) Nitrogen mustards alone. Decontamination and treatment are the same 
as for mustard. If early decontamination has been neglected, late decontami- 
nation should be performed even if erythema is already present and there is 
no evidence of liquid nitrogen mustard on the skin. The absorption of liquid 
nitrogen mustards through the skin is slower but more complete than that of 
mustard. Therefore, for the prevention of systemic toxicity, decontamination 
should be carried out as late as 2 to 3 hours after exposure, even at the ex- 
pense of increasing somewhat the severity of the local reaction. 



(e) Lewisite alone. If lewisite alone is used, BAL ointment is more ef-^ 
fective than protective ointment S-461 or S-330, and should be used, as BAL 
ointment is effective against all arsenical blister gases 'on the skin and pene- 
trates through the skin, neutralizing the agent which has been absorbed. 
Apply BAL ointment as described under Change in Standard Procedure, para- 
graph 3(b), (2) and (3). 

4. Subject ointments are listed in the Medical Department Supply Catalog as 



follows: 



Sl-3361 
Sl-3375. 



Ointment, BAL; 1/2 oz. tube 
Ointment, Protective S-461 and S-330; 3 oz. 
tube each 



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Burned News Letter, Vol. 5, No. 13 ^ RE STRICT T^n 



One (tube of Ointment BAL and one of ointment protective, preferably S-330, 
shall be provided with each gas mask. Nonmedical activities issuing gas 
masks shall request these items from the nearest medical supply depot or 
storehouse. Initial allowance for advance-base personnel will be included in 
the J15A and B components. It will be noted that ointment BAL is used on 
the skin and in the eye. 

5. In accordance with the policy to replace gradually all issues of Stock No. 
Sl-3375 Ointment Protective, formula S-461, by the formula S-330, all ad- 
vanced and forward areas, assault troops and combat forces, shall replace 
S-461 with S-330 as fast as the material becomes available in the areas. 
Activities in temperate and arctic climates and in rear areas where the pos- 
sibility of gas attack is remote will replace stocks of S-461 with S-330 when ( 
stock is available to meet all requirements. Formula S-461 for which replace- 
ment has been made by S-330 should be retained and held as a strategic re- 
serve. --BuMed. Ross T. Mclntire. 

+ **♦ + + 

ALNAV 100 BuMed ' 17 May 1945 

Subj: Defective Blood Plasma. ' 

Refer Alnav 86. Lot number defective human blood plasma erroneously 
reported. Correct to read 228395 (two two eight three nine five) . 

— SecNav. James Forrestai. 

+ * + * ( 

ALNAV 103 BuMed 22 May 1945 

Subj: Inoculation Against Cholera. 

Naval and civilian personnel traveling under cognizance of Navy Depart- 
ment stationed in and proceeding to or through India shall be inoculated 
against cholera. --SecNav. James Forrestai. 



- 24 - 



T med News Letter, Vol. 5, No. 



RESTRICTED 



To: 
Subj: 

Refs; 



All Ships and Stations. 

Penicillin - Supply, Employment, and 
Reporting of. 



BuMed-WM-CM 
L8-2/J]57(042-43) 

18 May 1945 



(a) Penicillin, Appeals for, to BuMed, L8-2/JJ57(042-43) , of 21 Aug • 
1943. 

Cb) Letter of Information and Instruction on the Use of Penicillin, 
L8-2/JJ5 7(042-43), of 7 Jan 1944. 

(c) Medical Stores: Penicillin, L8-2/JJ57(042-43) , of 7 Jan 1944; . 
AS&SL Jan-Jun 1944, 44-37, p. 344. 

(d) Penicillin Therapy of Gonococcus Infections, Modification of, . . 
L8-2/JJ57(042-43), of 23 Feb 1944; AS&SL. Jan-Jun 1944, 44-223, ' 
p. 359. 

Ce) Penicillin Therapy of Gonococcus Infections, L8-2/J]57(042-43), , ^ 
of 19 Aug 1944; AS&SL July-Dec 1944, 44-993, p. 212. 
Cf) Penicillin Therapy of Early and Latent Syphilis, L8-2/JJ57(042-43), 
of 15 Sep 1944; AS&SL July-Dec 1944, 44-1119, p. 215. 

(g) Penicillin Therapy, Report of Results of, L8-2/JJ57(042-43), of 
28 Oct 1944; N. D. Bui. of 28 Feb 1945, 45-193 Cenc. (A)). 

(h) Penicillin Therapy, Report of Results of, L8-2/JJ57C042-43), of 
17 Feb 1945; N. D. Bui. of 28 Feb 1945, 45-193. 

Ci) Penicillin Therapy of Early and Latent Syphilis, L8-2/J]57(042-43), 
of 13 Feb 1945; N. D. Bui. of 15 Feb 1945, 45-148. 
(j) "A Guide to Chemotherapy," BuMed News Letter, Vol. 5, No. 6, 
, pp. 8-11, of 16 Mar 1945. ~ 

1. References (a), (b), Cc), (d), (e), (f), (g), (h) and all other directives per- 
taining to penicillin, except reference (i) , are herewith canceled. 

. All monthly summaries of the use of penicillin, and the reporting of peni- 
cillin therapy in all diseases except syphilis, shall be discontinued. All supply 
on hand of Medical Supply Catalog item SI 6- 3081, NavMed 140, Penicillin 
Therapy Report, shall be discarded. 



2. (a) Penicillin appears in the Supply Catalog as follows: 



Stock No. 
Sl-1130 



Sl-1132 



Sl-1131 



Item 

PENICILLIN SODIUM, dry powder, 
100,000 Oxford units (equivalent to 
60-mg of pure crystalline penicillin) . 
PENICILLIN SODIUM, dry powder, 
200,000 Oxford units (equivalent to 
120-mg of pure crystalline penicillin). 
PENICILLIN CALCIUM, dry powder, 
100,000 Oxford units (equivalent to 
60-mg of pure crystalline penicillin) . 



Potency Period 
12 mo. 



Unit 
ajnpul/vial 



12 mo. ampul /vial 



12 mo. ampul /vial 



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Bii^jd News Letter, Vol. 5, No. i8(^) RESTRICTED 



Stock No. — Item 

Sl-1133 PENICILLIN CALCIUM, dry powder, 
200,000 Oxford units (equivalent to 
120-mg of pure crystalline penicillin) . 



Potency Period 
12 mo. 



ampul/Vial 



Unit 



Future replenishments to stock for issue to using activities will be made under 
stock numbers Sl-1132 and Sl-1133 (200,000 unit vials). Stock on hand under 
stock numbers SI -11 30 and SI -11 31 (in 100,000 unit vials) will be issued until 
present supply is exhausted. 

(b) Penicillin is now carried in stock at NMSD, Brooklyn, N. Y., and 
Oakland, Calif. Quantities requested should not exceed 1 months requirements 
except by activities to which shipment may be irregular. Penicillin on hand at 
any activity, which prospectively cannot be utilized within potency dating, shall 
be reported as exceiss, by air mail or dispatch, to BuMed (Material Division, ( 
Brooklyn) not less than 2 weeks prior to expiration dating. Such material will 
be ordered transferred to the nearest activity prepared to use it. 

3. The dried powder, when contained in ampules, is quite stable at ordinary 
room temperature, but high temperatures and prolonged exposure at room 
temperature cause significant deterioration. To assure maximum potency 
the ampules should therefore be stored in refrigerators. Though the penicil- 
lin expiration date is based upon preservation at ordinary refrigeration tem- 
peratures (+4P Or freezing temperatures will prolong the duration of potency. 
In liquid form penicillin is unstable. Solutions should be made up preferably 
just before administration, or at least daily and then kept under refrigeration 
at about +4° C. 

4. The recommended treatment plan for both early and latent syphilis is / 
40,000 Oxford units of penicillin administered by the intramuscular route 

every 3 hours day and night, making a total dosage of 2,400,000 units of peni- 
cillin given in 60 injections in 7 and 1/2 days. Penicillin is now considered 
the treatment of choice in early and latent syphilis. When used, it shall be re- 
ported as outlined in reference (i) . The follow-up studies required in this ref- 
erence are not being adequately reported to BuMed. All activities are urged 
to forward these reports as indicated in all cases of penicillin-treated syphilis. 
Only by thorough follow-up studies can the Bureau determine the success of 
this treatment plan. It is therefore suggested that, where practicable, personnel 
who have received the penicillin course of treatment for syphilis not be assigned 
duty during the ensuing 12 months to activities where facilities for proper 
follow-up studies do not exist. It is further urged that an individual case be 
considered a fa,ilure only when the Kahn titer fails to drop after 4 months has 
elapsed since the penicillin routine; or, if it rises after having diminished, in 
which case it is considered a serological relapse. Clinical relapse, of course, 
is an indication for retreatment. Retreatment for cases of serological fastness, 
serological relapse, or clinical relapse, should consist of 4,800,000 Oxford 



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units administered as 40,000 units intramuscularly every 3 hours day and 
night for 120 injections in 15 days. 

Several treatment plans are being studied by the Subcommittee on Venereal 
. Disease of the National Research Council. The regime herein recommended 
is part of this long-term program of study, and information accumulated to 
date indicates that none of the other treatment plans are superior to it. Study 
of the efficacy of penicillin in CNS syphilis is necessarily in its early stages, 
and no recommendations can be made at this time. 

5. Penicillin is considered the drug of choice in gonococcus infections-. Evi- 
dence is accumulating that the dosage should be larger than that originally 
recommended. Fewer failures will be encountered if 20,000 Oxford units of 
penicillin are given intramuscularly every 2 hours for 7 doses, totalling 
140,000 units. The possibility that penicillin therapy of gonococcus infections 
may mask, abort, or inhibit the development of concomitant cases of early un- 
diagnosed syphilis must be considered. When practicable, therefore, adequate 
recheck, including serology, of these patients is indicated for at least 3 months. 

6. For all other diseases, the dosage and route of administration of penicillin 
is left to the discretion of individual medical officers. Reference (j) was pre- 
pared to assist medical officers when questions arise as to the indications 
and dosage of penicillin in various diseases and infections. 

7. Occasional severe reactions still occur despite progressive improvement 
in purity of the products now on the market. When severe reactions are en- 
countered, the following data should be forwarded to BuMed: 

Diagnosis of case treated; reason for penicillin. 
Nature of reaction. 

Drugs prescribed concurrently with penicillin therapy. 

Has patient received penicillin prior to present administration? If so, 

give details. 
Method and dosage of present administration. 
Salt used. 
Diluent used. 

Manufacturer lot number, and expiration date of penicillin used. 
Additional pertiitent information, 

» 

8. Extensive studies are in progress in search of satisfactory methods to 
delay the absorption of penicillin. None have been perfected as yet. When 
safe and reliable methods have been proved, this information will be promptly 
disseminated. This applies also to the. oral administration of penicillin, which 
has recently received considerable publicity. Although the method appears to 
have merit, it remains to be proved that an adequate blood level of penicillin 
can be consistently attained. When administered orally in corn oil, or in 
water preceded by an alkaline buffer, four to five times the intramuscular dos- 
age is required. The expenditure of this quantity of refined penicillin does not 
appear justified at the present time, --BuMed. Ross T. Mclntire. 



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